Myth
Problem Gambling is not a problem if the individual engaged in Gambling behaviour is able to afford it.

Fact
Affordability has got no association with Problem Gambling. When the relationship to gambling takes priority over other areas of life eg spending more time in Gambling and less time with significant others to fulfil the roles such as the role of a spouse, partner, parent, employee etc. that becomes Problem Gambling.

Imagination is everything. It is the preview of life’s coming attractions

~ Albert Einstein

So you are motivated and have set goals. Now let us see if visualisation can help reinforcing the outcomes you wish to achieve.

We use visualisation in various models of psychotherapy including therapies for psychological trauma eg for PTSD, for health behaviour change eg using Solution Focussed Therapy in Addictions to name a few. Visualisation in simple terms simply means mental image rehearsal of the desired outcome. Not only used in Psychiatry, it can be used in everyday life by anyone to keep a positive attitude and reinforce behaviour required for the goals set by them.

For this to work, there are two essential elements

1. Detail

A detailed picture or image is needed. Carrying on from the original example of improving fitness, one has to develop a detailed image in their mind of what all would be done and how would it be achieved. The more the specific and detailed the image, the better are the chances of its achievement.

2. Rehearsal

After a detailed image, the next step is to practice visualising yourself doing that on any opportunity as possible.

So if you have made some resolutions for the New Year, make them SMARTand practice Visualisation to achieve them.

After the festivities of Christmas, many people think of improving their fitness, exercising more, detoxing from effects of alcohol, giving up smoking and contemplate other resolutions of the New Year. That is a good and a positive first step towards improvement of physical and mental health.

And in case you are in the process of deciding to give up smoking, then this video may help.

Once decided, you can take action by visiting your local GP, Stop Smoking Wales or an Addiction specialist to help and support you. There are various medications that can be used to help along with psychosocial support. The support is crucial to maintain the changed healthy behaviour. This support is particularly helpful in times when cravings or temptation to smoke in different situations are troublesome.

Walking through the streets of Central London today and thinking of Alcohol Awareness Week I was deliberating with my thoughts- Alcohol problems are found only in ‘blue collar’ population- is that really true? Not in my experience. I see ‘white collar’ professionals in clinical practice who develop a problematic relationship with Alcohol.

As reported in a recent BBC interview and campaigned by Alcohol Concern- Cymru, it often starts with recreational use where the reasons could be many- including coping with stress, using alcohol as a social lubricant to facilitate a subjectively improved social interaction, part of business networking world to name a few. This, when continues gradually results in gradual development of tolerance to the effects of alcohol and before long can be above ‘Hazardous Use’ giving way to ‘Harmful Use’ and ‘Dependence’.

In case stress is the underlying reason to seek shelter in Alcohol, then there are alternative and healthier ways to manage stress which I will be writing about in the next post.

But for now knowing what the considered safe limits are would be a start for Alcohol Awareness. For men, it is no more than 21 units and for women, no more than 14 units a week. These have to be spread out through the week with at least 2 days gap between drinking days. You can check your units consumption and calories onDrinkaware

Look out for ‘Managing Stress Healthily’ and ‘Acute Effects of Alcohol’ posts coming up shortly.

Ecstasy has been around for a very long time. Chemically it is 3, 4- methylenedioxymethamphetamine- MDMA. As the name suggests, it is a methamphetamine compound. It is taken orally usually in a tablet or capsule form and the effects start within 30- 60 minutes. Pharmacologically, there is a huge efflux of Serotonin in the brain along with effects on the Dopamine and Noradrenaline sytems as well.The acute effects can often lead to Hyperthermia (raised body temperature) which is compounded by its use in warm, humid climates typically found in the dance clubs and this can be life threatening. The euphoria that is often reported after its use seems to be more related to the contexts of the environment i.e. whether being used in isolation or with club goers and club environment. This has been seen in studies as reported in the 1st International Conference of Psychoactive Drugs in Budapest in March 2012.

Intoxication with Ecstasy has been described as occurring in three stages (Koesters et al, 2002; Parrott and Lasky, 1998)- initial stage of disorientation, second stage of ‘spasmodic jerking and tingling’ and the final stage of increased sociability, increased mental clarity, a feeling of emotional warmth and feeling close to others. Given the context dependent effects, higher doses can give rise to frank euphoria. In toxic doses it can lead to dehydration, hyperthermia (both these can be life threatening in club environment), raised pulse, hypertension, liver failure and/or renal failure (Jonas and Graeme- Cook 2001; Lester et al 2000). There may be anxiety, agitation and even confusion.

The post dose recovery time often leads to depressed mood, irritability, anxiety, sleep impairment, asociability. People who are regular users can experience mid week depression and there are reports of aggression as well.

The chronic effects after regular heavy use can be damaging. Several studies have now indicated that the SERT (Sertraline Transporter) is reduced with chronic use which highlights the diminution of Serotonin in various regions of the brain. As the effects of Ecstasy are on the Frontal Cortex (the part of the brain responsible for planning and executive function), cognitive and memory deficits can be significant. Interestingly, for me working as a Consultant Psychiatrist in Addictions in Wales, what I learnt new from the conference is also that heavy regular use can be associated with Sleep Apnea (serotonin being an important chemical in maintaining lung function).

Whilst experimenting with the drug may be tempting but it can lead to long lasting damage if it becomes persistent or heavy or dependent use.

The debate regarding the legislating evolving new drugs persists for Addiction Psychiatry. Whilst ‘Legal Highs’ (so called as they are not yet under legislation and illegal) keep growing, the issue of legislation needs to be carefully balanced by the understanding of scientific effects of these drugs.

The 1st International Conference on Novel Psychoactive Substances in Budapest, Hungary on 12- 13 March 2012 was a very useful conference which highlighted its theme of the rapidly changing world of ‘Legal Highs’. The biggest challenge for Addiction Psychiatry seems to be keeping pace with this rapid developments where newer drugs are coming out along with newer market evolution and the trends that are transgressing national and international borders- an impact of globalisation and the internet becoming a massive global market. Also, the epidemiology of these is not yet clear as the new drugs have been not around with us long enough. Fortunately though, EMCDDA is reporting that there are some prevalence studies coming up which may be reflecting the wide variation of use of these substances in different regions and countries. Other information reported in this conference, that is useful to me as a Private Psychiatrist in Wales, UK is that the Novel Psychoactive Substances are not probably the first preference of drug users and that stimulants- Amphetamines, Cocaine, MDMA & Ketamine remain drugs of preference. From the reported results, it seems that the Mephadrone might be on the decline. From Dr Paul Dargan’s findings, the other challenge that faces us in Addiction Psychiatry is that there are no systematic data on toxicology, the ICD coding takes a long time to code for new drugs and when faced with acute presentations which may be in A&Es, general medical wards, Psychiatry Wards or in Addiction services, the analytic confirmation is still not up to speed to be able to confirm or refute the drug in the body. Whilst most NPS seem to be falling under the categories of Piperazine, Cathinone and Synthetic Cannabinoids- variations in these poses clinical management challenges. Piperadole derivatives like DPMP and D2PM have been on the increase as highlighted in the conference and people after having used these have developed neuropsychiatric syndromes.

Similarly, the marketing of these has changed a lot and the newer social networking sites have been used a lot for advertising. Another MixMag survey had highlighted that the number of online shops has increased exponentially and the number of head shops have gone up as well. What struck me as well is that the products being sold with the same brand name such as ‘Ivory Wave’ has been found to be having no standardization, therefore the person buying the same brand may never be assured of getting the same drug on repeat orders. And Methoxetamine (Ketamine derivative) is being branded as “Bladder Friendly”.

What effects do these have in the long run is a difficult question to answer at the moment and a collaborative effort by clinicians, researchers, policy makers, criminal justice systems and governments is needed to address this new epidemic!

Working in Wales as a Consultant Psychiatrist specialising in Addictions, it is exciting to know and share the developments happening in Addiction Psychiatry.

Opiate dependence is a serious cause for concern and the dependence has evolved from illicit Heroin to other sources of Opiates as well such as Prescription Opioid Dependence. Buprenorphine is a valid treatment option and as with any other Chronic Health condition like Diabetes, Hypertension, Enduring Mental Health Problems- concordance to medication is a real clinical issue. We use Depot medication in cases of mental health disorders to improve medication concordance. The trial of Buprenorphine Implants may hold a promising future for Opiate Dependence Management as well. Watch the space!!

Alcohol Dependence is still a major cause of concern throughout UK. The issue of ‘minimum pricing’ is up for debate (probably for my next blog) but this post is about the use of Naltrexone in Alcohol Use Disorders. One of the mechanisms that Alcohol gives a pleasurable effect is through our Brain’s Opioid System. Naltrexone is an Opiate Blocker which is used for maintaining abstinence from Opiate Dependence and is licensed in UK in its Oral form. Several studies across the world have been done to demonstrate efficiency of other forms- Depot Naltrexone and Implants as well (most suited for motivated individuals).

Naltrexone has also been used over many years for Alcohol Use disorders for people in recovery, as it blocks the Opioid System, thus causing less pleasurable effects with drinking. The British Association of Pharmacology- Substance Misuse Guidelines have endorsed its use as well. Since it is not licensed in UK for this indication, only specialists in Addiction Psychiatry would generally prescribe this. Naltrexone has beneficial effects- one mechanism of ‘pharmacological extinction’ with Naltrexone and drinking alcohol may be possible but in my experience as a Consultant Psychiatrist in Wales, it has not caused a total extinction of the effects but has certainly helped people with reducing the amounts of alcohol they consume, the number of heavy drinking days and have reported that Alcohol does not affect them the same way as without the Naltrexone. One other effect is that the cravings to drink (which is a significant factor for relapse to heavy drinking) have reduced with Naltrexone.

The Naltrexone depot is a useful formulation which has its effect up to a month and aids concordance along with sustaining its effects. Vivitrol (US Preparation) is already licensed as a treatment for Alcohol Use Disorder in the USA. A similar preparation is available in UK, albeit in the Private Sector only.

The last British Gambling Prevelance Survey in 2010 showed that as high as 73% of the British Population had taken part in a gambling activity in the previous 12 months with National Lottery being the most popular. Fortunately though the Gambling Pendulum (Sakhuja 2011) swings predominantly on the left side to the centre with the amount of people with pathological gambling being the least out of the three- Social Gambling, Problem Gambling and Pathological Gambling. However, when it comes to Pathological Gambling, there are a lot of similarities with addiction (will be posting a recent presentation done for our department in my next post).

Treatments for this involve a combination of medication, psychological interventions and social interventions. One of the social intervention is Financial Management- Education and Debt Management. I am sharing a link by the UK government on Debt Management and this website has a wealth of free information on this topic.

In my next post, I will add the presentation and in subsequent posts will share the different treatments available on a private basis for Gambling Addiction in Wales by Serenity- Recover the Peaceful Way…